Your policy covers the least expensive care option that meets professionally recognized care standards. If you choose a more expensive care option when there is a less expensive care option, you are responsible for charges in excess of the less expensive care option. If clinical review criteria are used to determine whether a service is medically necessary, that clinical review criteria may be obtained by contacting us.
Predetermination is not required, but it is recommended. Predetermination is a way for Us to estimate of how Your recommended services will be covered under this Policy. Services that are not Medically Necessary or appropriate may not be covered. You should submit a request for an Advance Notice of Dental Care before services begin in the cases indicated.
Predetermination is not necessary for the following:
- Covered Services costing less than $500;
- Emergency services, but some notice of care is requested; or
- Oral examinations and prophylaxis.
Predetermination is suggested for the following service, if You are under nineteen (19) years of age:
- Medically necessary services or supplies;
- Periodontal scaling and root planing;
- Orthodontia, including preorthodontic treatment visit.
Predetermination is recommended for the following service at any age:
- Crowns, Anterior, except with posts or root canal;
- Crowns, 2 or more Posterior, except with posts or root canal;
- Inlays or Onlays, 2 or more, except with posts or root canal;
- Anterior composites;
- 2 or more multiple surfaces;
- Bridges – initial or replacement;
- Eligible partial dentures – initial or replacement;
- Periodontal surgery costing more than $500;
- Full bony impactions, two (2) or more.
We will send You and Your treating provider notice of Our determination within thirty (30) days of Our receipt of Your request.